Going into hospital

If you need to go into hospital, there is important information that you should take with you.

When you go into hospital, the staff there will require information about your needs and preferences. You or your health care team need to send:
  • your advance health care plan and/or directive
  • a summary of your health (including a record of symptoms and how they are managed)
  • a list of medications and any allergies.
Having a pack of this information ready to go at all times is helpful. A health care professional can help you to organise this. You and your family should know where it is in case you need to be transferred to hospital.

Returning home from hospital

When you come home after a stay in hospital, you and your family carers — along with everyone else involved in your health care — need to understand the care and support that you will need at home.

When you leave the hospital, doctors and community nurses will help to develop a health care plan that will be specific to your needs.

Case study

Mr & Mrs Clark

Mr Clark suffers from advanced chronic heart failure and has to go to hospital often. He lives with his wife, who is his carer, in their family home. When he is discharged from the hospital, special support is arranged for him.

First, a nurse explains Mr Clark’s condition to him and his wife. This nurse also explains the care he will need at home and provides a written plan to follow when he has symptoms.

Second, once Mr Clark is home, nurses and care workers visit daily (more often than before) to monitor his condition and help him with certain tasks, such as showering. These staff members have also received information from the hospital about the plan of care agreed with Mr and Mrs Clark and know whom to contact at the hospital if they have any concerns. When they visit, they check that the plan is understood.

As soon as Mr Clark experiences symptoms, he and his wife, supported by the community health care team, follow the plan they were given. This plan works well and he avoids having to go back into the hospital.

What the research shows

If you have advanced chronic heart failure, you are likely to benefit from extra support when you return home from hospital. This support should include education about managing your health and may make hospital readmission less likely.

If you are frail or generally unwell,* extra support when you come home from hospital can help you to stay in your own home for longer.

What the experts agree on

Whenever an older person in need of a palliative approach to care is discharged from hospital, health professionals need to check to see if there is support available to help that older person and/or their family carer as they readjust to managing at home.

What this means for older people

If you need to go into hospital, you or your family carer need to ask if there is extra support available for you when you come home. You may find this support very helpful as you adjust to managing at home again.

See the Community Care Guidelines for more details (see page 7).

Advice for carers

Care changes are often made when an older person is in hospital and these changes may need to be communicated to a number of carers and care workers in the home. Use a message board or notebook that all those providing care can use. This will help make sure that the correct care is given.


*with advanced life-limiting illness that is nonspecific or due to many illnesses